Even for the world of medicine this is big money, and a contentious issue.
By some estimates, about $6 billion to $8 billion could be saved each year if just a third of the patients with stable heart disease who undergo angioplasty were put on a careful regimen of diet, exercise and medications instead.
But which patients should be getting this medical therapy, and which should still have the invasive procedure?
Not even heart specialists at the same medical center always agree. That’s the case at St. Luke’s Hospital, site of a recent very public dust-up over when angioplasty is the right thing to do.
There’s no dispute that angioplasty during heart attacks saves lives — the tiny balloons that cardiologists inflate can open perilously blocked arteries.
But this same procedure also is done 400,000 times a year on stable patients when there’s no emergency. Often, it’s to relieve severe chest pains called angina; in some cases it’s for patients who have infrequent angina or no symptoms at all.
There’s mounting evidence, including research done at St. Luke’s, that many of these elective angioplasties aren’t needed. Patients do just as well with medical management, and at a considerable savings.
Findings like these prompted medical organizations to come up with angioplasty guidelines.
Last year, St. Luke’s researchers John Spertus and Paul Chan published a headline-making study showing that one in nine non-emergency angioplasties in the U.S. may be inappropriate, according to these guidelines.
Their findings came out just as national media were filled with reports of cardiologists accused of doing hundreds of questionable angioplasties.
Now, cardiologists Steven Marso and J. Aaron Grantham have published a rebuttal to their St. Luke’s colleagues.
They claim Spertus and Chan sensationalized their statistics. Add together the emergency and non-emergency angioplasties and overall, only 4 percent were inappropriate.
(Spertus and Chan did report that nearly 99 percent of emergency angioplasties were warranted, but didn’t give that as much discussion in their study.)
Marso and Grantham also object to the guidelines themselves, claiming the panel that set them didn’t include enough cardiologists who actually perform angioplasties and could give real-world advice.
So, angioplasty or medical management?
An editorial published alongside Marso and Grantham’s article proposes that doctors present patients with all the pros and cons and let them decide for themselves what is best.
Easier said than done, a new survey of Medicare patients suggests:
Only 10 percent of patients who received elective angioplasty said their doctor had ever discussed anything else as a serious option.